If you frequently have cold feet and toes, or pain in your legs, you should ask your doctor about peripheral artery disease (PAD). Many of the 8.5 million people in the U.S. who have PAD aren’t aware they have the problem, which is caused by fatty deposits in the arteries—most commonly the legs. As it progresses, PAD can narrow and harden arteries, restricting the flow of blood from the heart. PAD can potentially lead to such serious conditions as gangrene, loss of limb, and even death.

Yale Medicine vascular surgeons personalize their care for people with PAD by drawing from a toolbox of treatments that includes both traditional bypass surgeries and the latest minimally invasive endovascular approaches. These approaches use tiny instruments inserted into arteries and veins through small incisions.

“There has been an endovascular revolution that has transformed the treatment of these diseases completely,” says Cassius Iyad Ochoa Chaar, MD, a Yale Medicine vascular surgeon.  

Many of the lifestyle habits and problems doctors tell people to avoid can damage an artery’s inner layers and contribute to PAD. The culprits may include: excess weight; foods high in saturated fats, trans fats, salt and cholesterol; uncontrolled hypertension; and sedentary lifestyle.

Risk increases with age—12 to 20 percent of people who have PAD are over 60 years old. Smokers and people who have diabetes are also especially vulnerable.

PAD can be a silent disease, so, even if you have no symptoms, it’s important to talk to your doctor if you have such risk factors as family history or if you are over age 70.

When symptoms appear, they tend to be irregular and occur more often when you are active—especially when you are walking. If your PAD continues to progress, symptoms will probably occur with greater frequency, and you may start to experience them when you are not walking or otherwise being active.

These symptoms may include:

• Cold feet
• No pulse in the feet
• Achiness, burning, cramping, fatigue, heaviness, or pain in the legs and feet during activity or exercise
• Changes to the skin on the legs and feet, which can become thin and shiny
• Blue or purplish tinge to arms, legs or toes
• Wounds or ulcers on legs and feet
• Thinning hair on the legs
• Leg ulcers
• In men, erectile dysfunction

If the disease progresses, it may lead to gangrene, potential limb loss or even death.

Your doctor will perform a physical examination that will include checking the blood flow, pulse and pressure in your legs and feet. The doctor will look for anything unusual, such as color changes in your legs and wounds that are not healing. He or she may want an ankle-brachial index, which compares the blood pressure in your ankle with blood pressure in your arm.

Your doctor may also want to see imaging tests, including ultrasound, CT scan or MRI. 

Treatment for peripheral artery disease depends on the severity of the disease, your anatomy and the location of any narrowed arteries or blockages.

People who are diagnosed with early-stage PAD often can stop the progression of the disease by switching to a heart-healthy lifestyle, including establishing an exercise routine, losing weight if necessary and quitting smoking. Medications can help as well.

However, some cases of PAD involve obstructed arteries that only surgery can fix. 

There are several effective surgical treatment options for PAD. At Yale Medicine your surgeon will choose the least invasive method possible that will provide adequate long-term relief from your condition.

He or she may choose from several minimally invasive endovascular approaches, which involve making tiny incisions in the groin and threading a catheter, a long flexible tube with miniature surgical instruments on the end of it, into the artery. The surgeon will use X-ray imaging to determine the location and extent of the blockage, and to follow the progress of the procedure as he conducts it.

At the site of the blockage, the surgeon may perform one of the following procedures to remove or minimize the plaque or push it out of the way:

• Angioplasty: Using X-ray imaging for guidance, the doctor inserts a catheter with a tiny, sometimes drug-coated, deflated balloon on the end, and inflates the balloon to open the blockage.
• Stent: Angioplasty is often followed by the placement of a stent—a small, self-expanding metal tube that stays in place permanently to keep the artery open.
• Atherectomy: The surgeon uses a catheter with a sharp-bladed tool on the tip to scrape out plaque.

While some specialists only perform endovascular surgeries, Yale Medicine’s vascular surgeons are also skilled in traditional open bypass surgeries, which involves creating an alternative route so the blood can go around the blockage. This may be the best option if a previous angioplasty didn’t work, or there is some other reason why you are not a candidate for endovascular surgery. Bypass procedures require general anesthesia, and incisions that are large and long enough to allow the surgeon to view and work on blockages directly.

A bypass may involve replacing the damaged artery with a graft, which may be a plastic tube or a healthy vein from your body. The graft is placed in the leg with PAD so that blood can flow through it, bypassing the blockage.

In some cases, vascular surgeons may perform a hybrid surgery that uses both minimally invasive endovascular and traditional open approaches.

Recovery depends on the type of surgery you have. Recovery from minimally invasive endovascular surgery usually involves going home the same day and returning to all of your activities within two days.  

Open surgery typically involves hospitalization for two to five days. Most patients return to their full activities within a month. A short course of one to two weeks in rehabilitation is common after discharge from the hospital.

Your recovery depends on the severity of your PAD. Your symptoms may go away completely, or you may just experience an improvement, such as being able to walk longer distances. 

Yale Medicine's vascular surgeons have a depth of expertise in both traditional surgeries and the latest minimally invasive endovascular approaches.

Your Yale Medicine vascular surgeon will talk to you about your symptoms, educate you about the disease and discuss all surgical options with you. Together, you will decide on a personalized treatment that best fits the severity of your condition and the demands of your lifestyle.