What is peripheral artery disease?

PAD is atherosclerotic narrowing of the arteries that supply the legs. As plaque accumulates, less blood reaches the muscles and tissues. Mild disease causes intermittent claudication — calf, thigh, or buttock pain that comes on with walking and resolves with rest. As disease progresses to chronic limb-threatening ischemia (CLTI), patients develop pain at rest, non-healing foot wounds, and gangrene. Without timely revascularization, CLTI is a strong predictor of major amputation and death.¹

Symptoms across the spectrum

• Claudication — calf, thigh, or buttock pain reproducibly brought on by walking, relieved by a few minutes of rest. The location of the pain often points to the location of the disease (calf = SFA / popliteal; thigh = iliac; buttock = aortoiliac, sometimes with erectile dysfunction in Leriche syndrome)
• Rest pain — burning, aching foot pain at night that improves when the leg is dangled off the bed
• Non-healing wounds and ulcers — particularly on toes, heel, or pressure points, often in patients with diabetes
• Gangrene — black or dusky discoloration of toes or forefoot
• Cold, pale, or hairless legs; weak or absent pulses; slow capillary refill

How PAD is diagnosed

The cornerstone is the ankle-brachial index (ABI) — a simple, non-invasive ratio of ankle to arm blood pressure. ABI under 0.90 confirms PAD; under 0.40 suggests severe disease. In patients with calcified, non-compressible vessels (common in diabetes and end-stage renal disease), the toe-brachial index (TBI) and transcutaneous oximetry (TcPO₂) are more reliable. Pulse volume recordings, segmental pressures, and arterial duplex ultrasound add detail. Cross-sectional imaging — CT angiography (CTA) or MR angiography (MRA) — maps the disease before intervention. Severity is staged with the Rutherford and Fontaine classifications and, for CLTI, the WIfI (Wound, Ischemia, foot Infection) and GLASS (Global Limb Anatomic Staging System) frameworks.

How endovascular treatment works

The procedure is performed in a hospital interventional suite under local anesthesia with light sedation. Through a small needle access — usually the contralateral common femoral artery, sometimes ipsilateral antegrade or retrograde tibial / pedal access for below-the-knee disease — a thin catheter is advanced under live X-ray imaging to the diseased segment. Treatment is tailored to the lesion:

• Plain balloon angioplasty — the simplest and most common starting point
• Drug-coated balloons (DCBs) — paclitaxel- or sirolimus-coated balloons that reduce restenosis (Lutonix, IN.PACT, Stellarex, Ranger)
• Atherectomy — orbital (Diamondback), rotational (Jetstream), directional (HawkOne, Pantheris), or laser (Auryon, ELCA) for plaque modification
• Intravascular lithotripsy (IVL) — Shockwave technology for severely calcified vessels
• Stenting — self-expanding nitinol (Supera), drug-eluting (Eluvia, Zilver PTX), or covered (Viabahn) stents when needed
• CTO crossing — antegrade or retrograde pedal access and re-entry catheters (OUTBACK, Pioneer) for chronic total occlusions

Endovascular treatment vs. surgical bypass

The decision between endovascular therapy and surgical bypass — historically the dominant question in PAD — is now informed by the landmark BEST-CLI trial. In CLTI patients with a suitable single-segment great saphenous vein available for bypass, surgery had better limb-salvage outcomes. In patients without suitable vein, endovascular and surgical approaches performed similarly.² The right choice depends on anatomy, available vein conduit, comorbidities, and patient preference. For claudication, supervised exercise therapy and optimal medical therapy are first-line; endovascular treatment is reserved for lifestyle-limiting symptoms refractory to conservative care.³

Medical therapy is the foundation

PAD is systemic atherosclerotic disease, and the same plaque biology affects the heart and brain. Long-term antiplatelet therapy (aspirin, clopidogrel, or low-dose rivaroxaban after the COMPASS trial), high-intensity statin therapy, blood pressure and glycemic control, and smoking cessation reduce the risk of future heart attack, stroke, and limb events.⁴ Endovascular treatment opens the artery; medical therapy and lifestyle change keep it open and protect the rest of the vascular system.

References

1. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019;69(6S):3S–125S.e40.
2. Farber A, Menard MT, Conte MS, et al. Surgery or endovascular therapy for chronic limb-threatening ischemia (BEST-CLI). N Engl J Med. 2022;387(25):2305–2316.
3. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease. Circulation. 2017;135(12):e726–e779.
4. Anand SS, Bosch J, Eikelboom JW, et al. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial (COMPASS). Lancet. 2018;391(10117):219–229.

Frequently asked questions

What is peripheral artery disease?

PAD is atherosclerotic narrowing of the arteries that supply the legs. Mild disease causes leg pain with walking (intermittent claudication). Severe disease causes pain at rest, non-healing wounds, and gangrene — chronic limb-threatening ischemia (CLTI), where the limb itself is at risk.

What endovascular treatments are available?

Treatment is tailored to the lesion: plain or drug-coated balloon angioplasty, atherectomy (orbital, rotational, directional, or laser) for plaque modification, intravascular lithotripsy (IVL) for severely calcified disease, and stenting (self-expanding nitinol, drug-eluting, or covered) when needed. Chronic total occlusions are crossed using antegrade or retrograde pedal access and re-entry techniques.

Endovascular treatment versus surgical bypass — what does BEST-CLI tell us?

In CLTI patients who had a suitable single-segment great saphenous vein available for bypass, surgery had better limb-salvage outcomes than endovascular therapy. In patients without suitable vein, the two approaches performed similarly. The right choice depends on anatomy, available vein conduit, comorbidities, and patient preference.

Can endovascular therapy save my limb?

For many patients with CLTI, yes. Restoring inline blood flow to the foot — combined with wound care, podiatric debridement, and medical optimization — heals wounds and avoids major amputation in the majority of patients managed in a multidisciplinary limb salvage program.

Who performs PAD endovascular treatment?

At Florida Interventional Specialists, endovascular PAD treatment is performed by a board-certified interventional radiologist in close coordination with the patient’s primary care, endocrinology, podiatry, and wound care teams.